Indocyanine green (ICG) fluorescent cholangiography during laparoscopic cholecystectomy using RUBINA™ technology: preliminary experience in two pediatric surgery centers

Abstract

Background Recently, we reported the feasibility of indocyanine green (ICG) near-infrared fluorescence (NIRF) imaging to identify extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC) in pediatric patients. This paper aimed to describe the use of a new technology, RUBINA™, to perform intra-operative ICG fluorescent cholangiography (FC) in pediatric LC. Methods During the last year, ICG-FC was performed during LC using the new technology RUBINA™ in two pediatric surgery units. The ICG dosage was 0.35 mg/Kg and the median timing of administration was 15.6 h prior to surgery. Patient baseline, intra-operative details, rate of biliary anatomy identification, utilization ease, and surgical outcomes were assessed. Results Thirteen patients (11 girls), with median age at surgery of 12.9 years, underwent LC using the new RUBINA™ technology. Six patients (46.1%) had associated comorbidities and five (38.5%) were practicing drug therapy. Pre-operative workup included ultrasound (n = 13) and cholangio-MRI (n = 5), excluding biliary and/or vascular anatomical anomalies. One patient needed conversion to open surgery and was excluded from the study. The median operative time was 96.9 min (range 55–180). Technical failure of intra-operative ICG-NIRF visualization occurred in 2/12 patients (16.7%). In the other cases, ICG-NIRF allowed to identify biliary/vascular anatomic anomalies in 4/12 (33.3%), including Moynihan's hump of the right hepatic artery (n = 1), supravescicular bile duct (n = 1), and short cystic duct (n = 2). No allergic or adverse reactions to ICG, post-operative complications, or reoperations were reported. Conclusion Our preliminary experience suggested that the new RUBINA™ technology was very effective to perform ICG-FC during LC in pediatric patients. The advantages of this technology include the possibility to overlay the ICG-NIRF data onto the standard white light image and provide surgeons a constant fluorescence imaging of the target anatomy to assess position of critical biliary structures or presence of anatomical anomalies and safely perform the operation.

The Use of Indocyanine Green Fluorescence Angiography in Pediatric Surgery: A Systematic Review and Narrative Analysis

“…Multiple preliminary experiences have shown the safety and usefulness of ICG-FA in pediatric abdominal surgeries including minimally invasive surgeries (22,26), laparoscopic Palomo varicocelectomies (24), laparoscopic cholecystectomies (89), and laparoscopic partial nephrectomies (90). Currently, efforts are being made to standardize the technique and prove the benefits of the ICG-FA technology (89,90). A study published after the updated search of this review suggested a dose of 0.35 mg/kg of indocyanine green, 16-18 h before performing a laparoscopic cholecystectomy (89).…”

“…Currently, efforts are being made to standardize the technique and prove the benefits of the ICG-FA technology (89,90). A study published after the updated search of this review suggested a dose of 0.35 mg/kg of indocyanine green, 16-18 h before performing a laparoscopic cholecystectomy (89). The authors reported a 17% technical failure of intra-operative ICG fluorescence visualization (n = 2).…”

Usefulness of 4K-resolution Indocyanine Green Endoscope for the Removal of Spontaneous Intracerebral Hematomas

“…Finally, the intensity-map mode displays the ICG-NIRF signal intensity by changing the color according to the image type. 5 ) We used the overlay mode in this hematoma removal study. We performed ICG angiography using one ICG endoscope per case and compared the intraoperative findings.…”

“…The bleeding points are challenging to identify, and postoperative bleeding has been reported as a serious complication after endoscopic hematoma removal. 5 ) Therefore, we performed intraoperative ICG near-infrared fluorescence (ICG-NIRF) imaging to locate the bleeding point and identify the damaged vessel causing the hemorrhage. The purpose of the study was to evaluate the usefulness of ICG angiography during endoscopic hematoma removal.…”

Assessment of open-field fluorescence guided surgery systems: implementing a standardized method for characterization and comparison

“…Nevertheless, clinical trials have explored numerous uses that might be particular to individual devices, some of them being encompassed within 510(k) indications of use. For example, in gallbladder removal surgery (laparoscopic cholecystectomy) the RUBINA™ guided surgery system combined with an ICG contrast agent has helped to identify biliary and vascular tissues, as well as the presence of abnormalities that can cause complications during surgery 13 …”